Provider Demographics
NPI:1790934305
Name:PENALOZA, ROQUE ABEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROQUE
Middle Name:ABEL
Last Name:PENALOZA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1140 N PLEASANTBURG DR STE D
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-1256
Mailing Address - Country:US
Mailing Address - Phone:864-252-8296
Mailing Address - Fax:888-841-1350
Practice Address - Street 1:1140 N PLEASANTBURG DR STE D
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-1256
Practice Address - Country:US
Practice Address - Phone:864-252-8296
Practice Address - Fax:888-841-1350
Is Sole Proprietor?:No
Enumeration Date:2008-09-18
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0522491223G0001X
SC69921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice